the inconvenient truth about mental health and gun control

I’m still reeling from the tragedy that took place last week, trying to process the events and, like many people, wondering what can be done to prevent such a tragedy from befalling other families in our nation. I’ve seen a growing conversation on the need for better access to mental health services. As a therapist, I heartily agree that mental health needs to be available to everyone, regardless of ability to pay. I want nothing more than to see our country step it up in that regard.

However.

I don’t believe that better access to mental health services will solve the problem of gun violence. I’m going to do my best to illuminate the unique issues of mental health in relation to violence, and why I’m skeptical of focusing our attention on mental health instead of gun control as it relates to mass shootings.

First, I think it’s important to do some research into the psychological state of the perpetrator of such crimes. To be honest, I don’t love the use of the term “mentally ill” when we describe such people, because mental illness is an umbrella term that includes depression, anxiety, biploar disorder, eating disorders, and any number of other conditions that warrant treatment with a therapist or that result in a DSM diagnosis. It’s much too general a term to apply to violent behavior. By that definition, because I struggle with anxiety, I would be under the “mentally ill” umbrella. And again, while I’d love to see a national shift in treatment accessibility, I don’t think this is relevant to the conversation about killing sprees plaguing our nation.

I think it’s important to key in on the specific mental illness that is relevant to someone who would open fire on a group of strangers. While I can’t give a formal diagnosis since I‘ve never seen any of these people in treatment, the FBI did conduct some research into the kinds of people who commit such crimes, and found that most of these mass murders are committed by criminals who fall into three groups: psychopaths, the delusionally insane, and the suicidally depressed. In most cases, perpetrators of mass crimes were not in an active psychotic state. In most cases, the perpetrator premeditated the crime, planning willfully in advance as opposed to acting impulsively. In most cases, the perpetrator was described as a loner with few friends. Most were also described as intelligent. In every case, the perpetrator exhibited a shocking lack of empathy. In diagnostic terms, we would refer to psychopaths as having Antisocial Personality Disorder, whereas those suffering from delusions might be diagnosed with Schizophrenia.

Here are some of the problems with demanding accessibility to treatment as a prevention tactic for violent crime:

Most people with Antisocial Personality Disorder or Schizophrenia do not seek treatment. In fact, not only do they not seek it out, they are usually completely resistant to it, and find ways to avoid it. The reason for this is that sociopaths are convinced that there is nothing wrong with them. They usually have a heightened sense of their own mental state. With most mental illness, the person suffering has both subjective and objective issues. For example, a person with depression experiences it subjectively (“I feel bad”) and those around them experience it objectively (“You seem depressed”). With Antisocial Personality Disorder (and many of the personality disorders), that subjective experience of distress is lacking. While those around them may experience them as cold, calculating, manipulative, or cruel, the sociopath believes himself to be just fine. Similarly, people with schizophrenia may feel some disturbance, but are likely to view the disturbance as an external problem rather than something internal that requires treatment.

Antisocial Personality is a chronic, lifelong condition with a poor treatment prognosis, and Schizophrenia is a late-onset mental illness that is usually chronic as well. In the Diagnostic and Statistical Manual (DSM) that doctors and therapists refer to for diagnosis of patients, there are two categories under which mental health issues can fall. Axis I refers to most mental health issues, and includes things like depression, anxiety, bipolar disorder, and schizophrenia. Axis II refers to lifelong conditions that are considered difficult to treat. This includes mental retardation, borderline intellectual functioning, and the personality disorders (including APD). It’s not to say that these people won’t benefit from therapy. But with mental retardation and personality disorders, most therapists accept that you are not going to “cure” the patient or even be able to treat the condition. Rather, you will offer support and resources and behavioral interventions for people living with these conditions. I wouldn’t go as far as to say that antisocial personality disorder is untreatable. But I will say that most with this disorder are unresponsive to treatment, and that many with this condition use therapy as a milieu to practice manipulation rather than as an opportunity for growth. S

Antisocial Personality Disorder is difficult to diagnose. Most people with APD will never receive a formal diagnosis. There are many reasons, but primarily it’s because they don’t tend to seek treatment or view themselves as having an issue. Therefore, they avoid contact with mental health professionals who would be able to offer a diagnosis. Friends and family may notice that something is “off”, but they will likely view it in terms of negative character traits “He’s so insensitive”, “She is really manipulative”, “He has serious intimacy issues”, etc. Since antisocial people can be superficially charming, and because they tend to be highly intelligent, they can usually fool people . . . even professionals.

We cannot legislate treatment or isolation of people with APD or Schizophrenia. They will always be in the general public, and most of the time they will go undiagnosed. We cannot force them into treatment. We cannot isolate them. We cannot go on a witch hunt, trying to diagnosis every person we know who struggles with intimacy or empathy as being a sociopath.

So what can we do?

We can change our gun laws to make sure that only mentally competent people can own a gun.

Would this be challenging? Yes. Would it require people to pay more out of pocket to obtain a gun? It would. Might I have to pay some more taxes for this? Yep, but I’m willing. If I have to take a test to prove my ability to safely operate a motor vehicle, it only makes sense that we would apply the same criteria to gun possession in our country. It’s the best way to rule out people with mental health issues that are highly correlated with antisocial and violent behavior.

Here are some ways that we could do that, while maintaining 2nd amendment rights for a majority of the population.

Require an MMPI to possess a gun. The MMPI is a time-tested, scientific diagnostic tool widely used by psychologists to determine a person’s mental state. It is excellent at catching antisocial tendencies, as well as psychotic tendencies. It would be an easy and cost-effective way to rule out people who shouldn’t be gun owners, and I think this step would be a small price to pay for those who want to own a gun, but who have enough decency to want to keep them out of the hands of people who would misuse them. And while I’m focusing on mass shootings, I will note that the MMPI could also rule out people who have issues that are highly correlated with suicide or other violent behaviors.

Require three references to possess a gun. This step is required in many countries, and could be very effective. Most people with antisocial behavior are loners, and those they are in relationship with probably see some of their sociopathic tendencies. Requiring a reference letter from three people that asks pointed questions in regard to their mental state would be one more measure to ensure that sociopaths are weeded out.

Require that gun owners be educated on APD and other violent markers. In most cases, perpetrators of mass killings either obtain a gun themselves, or use a gun owned by family or friends. It would be helpful, then , to require that anyone seeking to own a gun be educated for the warning signs of violent tendencies. Many people may not connect the dots, and requiring education could be the measure that clues a parent in on a potential threat and is therefore more careful with their weapons.

Require that gun owners demonstrate how their firearms will be inaccessible to family, friends, and roommates. Too often, personal firearms are stored in ways that allow access to others. My parents were gun owners, and I knew exactly where the gun was in our house. This can encourage not only intentional, violent crime, but also unintentional gun accidents. I think we need to change laws so that guns must be on your person or in a lockbox. Better yet, require that guns be sold with a lockbox.

Limits the types of firearms and the amount of ammo that can be purchased. As I mentioned before, most mass shooters have purchased both their guns and their firearms legally. In most cases, assault rifles have been used to carry out mass shootings. It makes sense: that’s what these guns were created for. I have to ask, then, why is such a weapon available to the general public? Guns should be used for hunting or for self-defense. I don’t think our forefathers had any concept that their words would be used to invoke a person’s right to own a machine that allows them to kill dozens of people in a few seconds. There are many compelling arguments to banning assault weapons, and I think it’s time for us to assess, as a nation, why we are allowing such guns to be legally sold in our country. I would agree that a madmen hell-bent on killing a lot of people is going to find a way. But we can make it harder for them but not having these guns available. I think the comparison of the man in China who attempted to kill children with a knife is an example. If you compare the death toll between Newtown and this incident, it’s a compelling reason to outlaw assault rifles. I also think we should limit the amount of ammo that can be purchased, and the amount of bullets that a single gun can shoot before reloading. I can’t think of a single legal incident that would require a gun owner to shoot off 50 rounds before reloading. And yet, this week certainly reminds us why this kind of ammunition is problematic. Senator Feinstein is introducing a bill to the Senate that will ban the sale, transfer, and the possession of assault rifles, as well as big clips, drums or strips of more than 10 bullets. I think this is reasonable. If you do, too, I urge you to lead your political leaders know.

I’m not going to pretend like these measures will solve all of our problems. We will always have madmen living in the general population. However, we can make it more difficult for them to obtain guns. And while it may not keep guns out of the hands of all criminals, it might keep them out of the hands of sociopaths. See . . . sociopaths are not common criminals. They don’t run in circles of criminals. They are loners, and usually buy their weapons legally or take them from a friend. They don’t have connections with people who sell illegal firearms. They don’t have many connections, period. And while they could still obtain a gun illegally, I think it could be a deterrent.

Of course, the common criminal will still have access to guns, but the common criminal is typically not bent on killing random civilians. And again, I’m not saying we criminalize guns. I’m saying we rule out the people who shouldn’t have them so they cannot buy them legally.

I do believe that making mental health treatment more accessible will prevent some types gun violence. Suicide, domestic violence, “crimes of passion” . . . there are many types of violence that could potentially be circumvented by counseling. In addition, better access and support of families and children with mental health issues could even prevent some children from developing APD, which begins in childhood. But we can’t end there. It’s not enough. It doesn’t address the horror that can be wreaked by a sociopath with a gun. We need to talk about mental health. And we need to talk about gun control.

This isn’t a partisan or a political issue, though some will pretend it is. This isn’t a 2nd amendment issue, though some will cry that it is. I think the ideas I’ve outlined above are things that can keep both gun enthusiasts and gun control ideologists happy. But we’ve got to do something. The events of last week illustrate that we can’t keep making excuses. We need to call our legislators into action. If you agree, I hope you will share this with your friends, but more importantly with your congressional leaders. It’s time to speak up. If my child was one of the fallen, it’s what I hope you would do for me. It’s what survivors are asking us to do, too. Even pro-gun, NRA-promoted politicians are calling for change.